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Health Assessment Theory > Skin > Flashcards

Flashcards in Skin Deck (14)
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1
Q

For inspection, look for

A

pallor
redness
wounds

2
Q

When documenting a wound should you describe it or label it as the type of wound

A

just describe it- length, width, depth, square/oval/round, discharge/exudate, color, odor

3
Q

When describing never use the word

A

approximately

4
Q

What measurement scale should be used

A

cm

5
Q

What is a fistula

A

abnormal connection between two hollow spaces

6
Q

What is blanchable

A

if you press on it the color will go away

7
Q

What is a stage 1 pressure ulcer

A

non-blanchable redness, closed

8
Q

What is a stage 2 press ulcer

A

open, red, and shallow wound

partial skin loss of the dermis

9
Q

What is a stage 3 press ulcer

A

open, subQ fat is visible

10
Q

Do you document the redness around the wound with the description of the wound

A

no, describe the redness around the wound separately

11
Q

What is a stage 4 press ulcer

A

open, usually tunneling, down to the bone, might be eschar

12
Q

If there is eschar covering up enough of the wound to where you can’t see any fat or bone what is it classified as

A

unstable

13
Q

For palpation assess for

A

diaphoresis
temp
turgor
texture (weak?)

14
Q

What is one of the first things that you should almost always do if your patient is getting worse

A

get a blood sugar